THE CHALLENGE
For hospitals, high-level severity denials are a major challenge resulting in increased administrative, clinical and financial burdens. One major concern is the dodging of the Two-Midnight rule, which was finalized under CMS-4201-F in April of 2023. The Two-Midnight rule sets the precedent that patients are appropriate for inpatient admission if the admitting physician expects the patient to require at least two midnights of hospital-level care, corroborated by the medical record supporting inpatient (IP) level of care (LOC). These lower-level of severity (LLS) determinations, however, circumvent the Two-Midnight rule by “approving” the IP stay, but at a reduced reimbursement, which is often in line with observation LOC reimbursements.
Additionally, LLS determinations allow the payer to avoid the regulatory rules that apply to denials since the stay was never actually denied at the inpatient level, but rather downgraded to the LLS rate.
THE SOLUTION
AppriseMD believes the only solution to the strain these LLS determinations put on hospital revenue cycle teams is to challenge these reimbursement denials. AppriseMD has been conducting severity discussion reviews since January, and our physician advisor team has a solid success rate of invalidating the LLS determinations to maximize revenue. AppriseMD serves hospital clients in 25 states and offers these severity discussion reviews at the same rate that peer-to-peer payer reviews are offered.
An AppriseMD physician advisor recently overturned an LLS determination by engaging in a severity clinical discussion with the payer. This discussion included the fact that the patient required a higher intensity medical management on the days leading up to his discharge.
LEVEL OF SEVERITY CLINICAL SUMMARY
The patient is a 69-year-old male with history of diabetes, CAD s/p stent, chronic kidney disease, paroxysmal atrial fibrillation on Warfarin and hypertension, who presented to the emergency department with lightheadedness, falls and failure to thrive.
On arrival, he was mildly tachycardic and hypertensive. Laboratory studies were notable for an elevated glucose level of 395 and Trop T of 26>29 (reference <16 ng/L). The electrocardiogram showed sinus tachycardia with no evidence of ischemia and unchanged compared to previous studies. A chest X-ray demonstrated no acute findings, and a CT of the head was negative for intracranial abnormalities.
On physical examination, the patient was noted to have multiple skin lesions on the upper extremities, torso, abdomen and bilateral lower extremities, in various stages of healing. A wound care consultation was obtained.
The patient’s glucose remained elevated throughout the hospitalization, and a Hgb A1C was obtained, which was 9.1%, indicating poor glycemic control. During the admission, the patient’s glucose levels reached the 400-500 range and remained uncontrolled; therefore, basal-bolus insulin therapy was initiated. The patient worked with occupational therapy and reported worsening pain, for which tramadol was administered. Despite this, he was able to ambulate with the assistance of a walker. Over the course of the hospitalization, his glucose level demonstrated improved control. Physical therapy was arranged for outpatient follow-up, and the patient was deemed medically stable. He was subsequently discharged to home in a safe condition with home health services.
SEVERITY DISCUSSION OUTCOME
After reviewing the medical record, an AppriseMD physician advisor facilitated the severity discussion with the payer medical director. The AppriseMD physician advisor communicated that the patient had uncontrolled diabetes, labile blood glucose, multiple open skin lesions requiring medical treatment and was admitted due to lightheadedness and falls. The patient was not taking insulin prior to admission; however, basal-bolus insulin was initiated due to uncontrolled hyperglycemia. The patient’s persistent hyperglycemia of 479 on day three, followed by a reading of 513 on day four, required escalating doses of basal-bolus insulin each day. For these reasons, the patient was not medically ready to be discharged, demanding a higher intensity of medical management. Upon completion, AppriseMD was able to overturn the LLS reimbursement, resulting in high-severity approval to ensure appropriate reimbursement for the hospital.
ABOUT APPRISEMD
AppriseMD provides denial management and physician advisory solutions to help hospitals and health systems optimize the revenue cycle with data transparency and operational efficiency.